Using Lasers & EBDs for Pigmented Lesions & Tattoos

During the 2023 Skin of Color Update in New York City, Dr. Omar Ibrahimi, a renowned laser and cosmetic dermatologist, as well as a Mohs surgeon in private practice in Stamford, Connecticut, imparted valuable insights into the use of lasers for pigmented lesions and tattoos. Dr. Ibrahimi placed significant emphasis on ensuring both safety and efficacy, particularly in individuals with diverse skin tones. Recognizing the challenges faced by individuals of various ethnicities seeking laser treatments, he emphasized the need for a nuanced understanding of skin characteristics, utilization of appropriate devices, and effective management of patient expectations.  His extensive coverage spanned pigmented lesions, photoaging, tattoos, and birthmarks, offering essential considerations for achieving successful outcomes. For those unable to attend the lecture, here is a concise overview of the key points he addressed.

PIGMENTED LESIONS

Dr. Ibrahimi emphasized the critical importance of obtaining a clinical diagnosis before initiating treatment, especially for pigmented lesions, as misdiagnosis could lead to overlooking melanoma. Despite being less common in patients with skin of color, melanoma can still occur, and treating it with lasers could have severe consequences.¹ He stressed the need for relying on personal clinical judgment rather than that of colleagues, as ultimately, the treating physician is held accountable. Dr. Ibrahimi’s memorable quote from his presentation was, “To treat a lesion cosmetically, you must be competent medically.”

Discussing various studies, Dr. Ibrahimi explored treatment modalities such as Q-switched and picosecond lasers. He highlighted the significance of understanding laser tissue physics, identifying treatment endpoints, and setting realistic expectations. Case studies that were presented illustrated successful outcomes and the importance of personalized approaches.

Lentigines and Ephelid Management:

Potential laser options for treatment include Q-switch lasers, long-pulsed alexandrite lasers, long-pulsed dye laser (PDL), potassium-titanyl-phosphate (KTP), and picosecond lasers. Dr. Ibrahimi advised erring on the side of undertreatment to minimize side effects with overtreating, as all these laser modalities carry associated risks. He cited studies comparing different pigment lasers:

• • One study showed that Q-switched laser and long-pulsed alexandrite laser were both effective in treating freckles and lentigines in oriental patients, however Q-switched laser was associated with a 3-fold risk of developing PIH.²
  • Another study comparing 4 different pigment lasers found that risk of PIH was greatest with long-pulsed alexandrite laser followed by Q-switched laser and there was no risk with long pulsed-dye laser (PDL) or potassium-titanyl-phosphate (KTP).³

Dr. Ibrahimi emphasized that the desired endpoint when using a Q-switch or picosecond device is whitening.

Dermatosis Papulosa Nigra Management:

Dermatosis Papulosa Nigra (DPN), akin to seborrheic keratoses, tends to appear in patients of African American heritage and accumulates with age. While challenging to treat, one study showed significant improvement after three treatments with a non-ablative fractional 1550-nm laser.⁴ Another study demonstrated equally good cosmetic outcomes with PDL, curettage, and electrodessication, though all modalities were associated with PIH.⁵ Patients should be informed that complete clearance may not be achievable, and follow-up treatments may be needed for maintenance.

Melasma Management:

Acknowledging the complexity of melasma, Dr. Ibrahimi suggests laser treatments as part of a multi-modality approach. Though not considered first- or second-line treatments, fractional resurfacing lasers and energy-based devices may be considered a third-line treatment for melasma and may help speed up treatment outcomes.⁶  Studies supported the use of fractional lasers, picosecond devices, and laser-assisted drug delivery for faster results. Dr. Ibrahimi explained that combining lasers with topicals is effective because the fractional laser impairs the skin barrier, allowing augmented delivery of topical medications. This concept is referred to as laser-assisted drug delivery. Below are some of the studies referenced by Dr. Ibrahimi:

• • 1550-nm non-ablative fraction lasers can quickly clear melasma, however this is temporary and may require more sessions in the future.⁷
  • Q-switch Nd:YAG laser treatment immediately following microdermabrasion every 4 weeks led to improved melasma with remission lasting at least 6 months.⁸
  • Picosecond lasers, which involve shorter pulses that are up to 100 times faster than Q-switched devices, have minimal downtime and may be used for improvements in skin texture and diffuse pigmentation. Dr. Ibrahimi suggests the following treatment protocol: 1064-nm, 6-8 mm spot, 0.6-1.0 J/cm2, 750 ps.
  • 1927-nm fractional thulium fiber laser combined with topical tranexamic acid led to greater clearance than with thulium laser monotherapy.⁹

Post-inflammatory Hyperpigmentation Management:

Dr. Ibrahimi is passionate about addressing post-inflammatory hyperpigmentation (PIH) and has explored several laser treatment options supported by scientific research:

• • Microsecond Nd:YAG demonstrated significant improvement one month after four treatments, with near clearance observed six months after ten laser treatments.¹⁰
  • Laser-assisted drug delivery, combining a 1927-nm fractional thulium fiber laser with topical tranexamic acid for an average of 3.3 treatments, resulted in complete, excellent, or good clearance of PIH in all patients.⁹ Notably, Dr. Ibrahimi shared his successful use of this method for PIH secondary to a nasal tip punch biopsy.

Birthmark Treatment:

Drawing from his residency training at Massachusetts General Hospital, Dr. Ibrahimi shared insights on treating birthmarks, underscoring the impact on patients’ quality of life. He advocated for early intervention and presented studies supporting the safety and efficacy of laser treatments:

• • Q-switched Nd:YAG laser improved Nevus of Ota in 50 adult patients from India after an average of five sessions.¹¹
  • Retrospective chart reviews showed significant improvement in children with phototypes IV-VI treated with Q-switched Nd:YAG laser for Nevus of Ota.¹²

Early intervention is preferred due to thinner and less pigmented younger skin, allowing better laser penetration and preventing psychosocial distress associated with discoloration later in life. Dr. Ibrahimi also shared his experience treating a facial epidermal nevus with CO2 resurfacing laser, emphasizing the importance of a test spot prior to treating the entire area.

INFRAORBITAL DARK CIRCLES

Management:

Infraorbital dark circles may arise from multiple factors including issues with vascularity, age-related melanin overproduction, or age-related skin thinning. Dr. Ibrahimi highlighted the efficacy of Q-switched lasers in treating this issue.^13,14 He emphasized the vital need for eye protection to minimize the risk of eye damage given the presence of melanin in the retina.

TATTOO REMOVAL

Considerations and Cautions:

Dr. Ibrahimi discussed challenges in tattoo removal, particularly in darker skin tones, emphasizing the risks of scarring and hyper/hypopigmentation. Understanding laser tissue physics is crucial, with different wavelengths corresponding to tattoo colors. Dr. Ibrahimi underscored the necessity of test spots, palpation, and careful assessment of tattoos prior to treatment. This is especially important when treating colored tattoos in patients with darker skin tones because melanin is a competing chromophore.

In conclusion, Dr. Ibrahimi gave a wonderful lecture illustrating the transformative impact of laser treatments on patients’ lives. He encourages fellow dermatologists to continue refining their skills in treating diverse skin tones, offering hope for those seeking solutions to pigmented lesions.

References:

1. 1. Stankiewicz, K., Chuang, G., & Avram, M. (2012). Lentigines, laser, and melanoma: a case series and discussion. Lasers in surgery and medicine, 44(2), 112–116. https://doi.org/10.1002/lsm.21148
   2. Ho, S. G., Yeung, C. K., Chan, N. P., Shek, S. Y., & Chan, H. H. (2011). A comparison of Q-switched and long-pulsed alexandrite laser for the treatment of freckles and lentigines in oriental patients. Lasers in surgery and medicine, 43(2), 108–113. https://doi.org/10.1002/lsm.21045
   3. Ho, S. G., Chan, N. P., Yeung, C. K., Shek, S. Y., Kono, T., & Chan, H. H. (2012). A retrospective analysis of the management of freckles and lentigines using four different pigment lasers on Asian skin. Journal of cosmetic and laser therapy : official publication of the European Society for Laser Dermatology, 14(2), 74–80. https://doi.org/10.3109/14764172.2012.670707
   4. Katz, T. M., Goldberg, L. H., & Friedman, P. M. (2009). Dermatosis papulosa nigra treatment with fractional photothermolysis. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 35(11), 1840–1843. https://doi.org/10.1111/j.1524-4725.2009.01302.x
   5. Garcia, M. S., Azari, R., & Eisen, D. B. (2010). Treatment of dermatosis papulosa nigra in 10 patients: a comparison trial of electrodesiccation, pulsed dye laser, and curettage. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 36(12), 1968–1972. https://doi.org/10.1111/j.1524-4725.2010.01769.x
   6. Bolognia, J. L., Schaffer, J. V., & Cerroni, L. (2018). Disorders of Hyperpigmentation. In J. L. Bolognia, J. V. Schaffer, & L. Cerroni (Eds.), Dermatology (4th ed., pp. 1115-1143). (Elselvier).
   7. Rokhsar, C. K. & Fitzpatrick, R. E. (2005). The Treatment of Melasma with Fractional Photothermolysis. Dermatologic Surgery, 31 (12), 1645-1650.
   8. Kauvar A. N. (2012). Successful treatment of melasma using a combination of microdermabrasion and Q-switched Nd:YAG lasers. Lasers in surgery and medicine, 44(2), 117–124. https://doi.org/10.1002/lsm.21156
   9. Wang, J. V., Lopez, A., & Geronemus, R. G. (2022). Safety and Effectiveness of Low-Energy, Low-Density 1927-nm Fractional Thulium Fiber Laser With Tranexamic Acid for Postinflammatory Hyperpigmentation. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 48(10), 1131–1133. https://doi.org/10.1097/DSS.0000000000003591
   10. Battle, E. F., Jr, & Soden, C. E., Jr (2009). The use of lasers in darker skin types. Seminars in cutaneous medicine and surgery, 28(2), 130–140. https://doi.org/10.1016/j.sder.2009.04.003
   11. Kar, H. K., & Gupta, L. (2011). 1064 nm Q switched Nd: YAG laser treatment of nevus of Ota: an Indian open label prospective study of 50 patients. Indian journal of dermatology, venereology and leprology, 77(5), 565–570. https://doi.org/10.4103/0378-6323.84057
   12. Belkin, D. A., Jeon, H., Weiss, E., Brauer, J. A., & Geronemus, R. G. (2018). Successful and safe use of Q-switched lasers in the treatment of nevus of Ota in children with phototypes IV-VI. Lasers in surgery and medicine, 50(1), 56–60. https://doi.org/10.1002/lsm.22757
   13. Xu, T. H., Yang, Z. H., Li, Y. H., Chen, J. Z., Guo, S., Wu, Y., Liu, W., Gao, X. H., He, C. D., Geng, L., Xiao, T., & Chen, H. D. (2011). Treatment of infraorbital dark circles using a low-fluence Q-switched 1,064-nm laser. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 37(6), 797–803. https://doi.org/10.1111/j.1524-4725.2011.01956..x
   14. Alavi, S., Goodarzi, A., Nilforoushzadeh, M. A., Mansouri, P., Jafari, M. A., Hejazi, S., & Azizian, Z. (2022). Evaluation of Efficacy and Safety of Low-Fluence Q-Switched 1064-nm Laser in Infra-orbital Hyperpigmentation Based on Biometric Parameters. Journal of lasers in medical sciences, 13, e16. https://doi.org/10.34172/jlms.2022.16

This information was presented by Dr. Omar Ibrahimi during the 2023 Skin of Color Update conference.  The above highlights from his lecture were written and compiled by Dr. Sarah Millan. 

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